Get SSA-795 2020
Form Approved OMB No. 0960-0045 Social Security Administration STATEMENT OF CLAIMANT OR OTHER PERSON Name of Wage Earner Self-employed Person or SSI Claimant Name of Person Making Statement If other than above wage earner self-employed person or SSI claimant Relationship to Wage Earner Self-Employed Person or SSI Claimant Understanding that this statement is for the use of the Social Security Administration I hereby certify that - Form SSA-795 09-2015 ef 09-2015 Destroy Prior Editions I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement about a material fact in this information or causes someone else to do so commits a crime and may be subject to a fine or imprisonment. SIGNATURE OF PERSON MAKING STATEMENT Signature First name middle initial last name Write in ink Date Month day year Telephone Number Include Area Code Mailing Address Number and street Apt. No* P. O. Box Rural Route City and State ZIP Code Witnesses are required ONLY if this statement has been signed by mark X above. If signed by mark X two witnesses to the signing who know the individual must sign below giving their full addresses. 1. Signature of Witness Address Number and street City State and ZIP Code Privacy Act Statement Collection and Use of Personal Information Section 205a of the Social Security Act 42 U*S*C. 405a as amended authorizes us to collect the information on this form* We will use this information to determine your potential eligibility for benefit payments. Furnishing us this information is voluntary. However failing to provide us with all or part of the requested information may affect our ability to evaluate the decision on your claim* We rarely use the information you provide for any purpose other than for determining entitlement to benefit payments. However we may use the information you give us for the administration and integrity of our programs. We may also disclose information to another person or to another agency in accordance with approved routine uses which include but are not limited to the following 1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and/or coverage 2. To comply with Federal laws requiring the release of information from our records e*g* to the Government Accountability Office and the Department of Veterans Affairs 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal State and local level and 4. To facilitate statistical research audit or investigative activities necessary to assure the integrity and improvement of Social Security programs. We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal State or local government agencies. We use the information from these programs to establish or verify a person s eligibility for federally-funded or administered benefit programs and for repayment or incorrect payments or delinquent debts under these programs.
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